Global child survival rates have risen since 1990 and facility births have increased. Yet improvements in neonatal mortality rates have lagged. From 1990-2020, this measure declined at a slower rate than post-neonatal under-5 mortality. Notably, virtually all (99%) of the children who died within the first four weeks of life were in the world’s poorer regions, with sub-Saharan Africa (SSA) and South Asia being the most affected. In fact, the SSA region has the highest neonatal mortality rate in the world, with 27 deaths per 1000 live births, accounting for 43% of global newborn deaths.
The first month of life, particularly the first week, is the most crucial time for survival. In 2020, 2.4 million newborns died globally, with 75% of those deaths occurring within the first week. Most deaths within the first 28 days of birth are traced to health problems linked to inadequate care during delivery and the initial hours and days afterward. Causes include premature birth, complications during delivery (such as birth asphyxia, i.e., the inability to breathe at birth), infections, and birth defects.
Nutrition is one key to addressing neonatal mortality. Premature and low birth weight neonates are born at a nutritional disadvantage—they have greater nutrient requirements than other newborns, metabolic and gastrointestinal immaturity, and related problems. Human milk is the optimal choice for feeding them (and all infants). When a mother’s milk is unavailable or in limited supply, donor milk is the next best alternative. Despite some nutritional elements being lost during pasteurization, donor milk still offers documented advantages over formula.
Our recent study, conducted at Pumwani Maternity Hospital in Nairobi, Kenya, found that a human milk bank (HMB) and lactation support program led to dramatic increases in newborn feeding with human milk and a reduction in average days spent in neonatal care.
Improving neonatal feeding practices is one element of a broader set of efforts to provide high coverage of skilled maternal and newborn care that can improve the health of newborns and prevent stillbirths—improving survival rates. This encompasses quality antenatal care, skilled care during birth, postnatal care for both mother and baby, and appropriate care for small and sick newborns. Our results suggest that scaling up donor human milk programs can be a promising approach to address the staggering and unacceptably high neonatal mortality in the SSA region, including Kenya.
The Pumwani Maternity Hospital study
The government-owned Pumwani Maternity Hospital is the largest facility of its kind in Kenya. Founded almost a century ago, it is one of the oldest health facilities in Africa and treats the highest number of maternity and critically ill newborns of any hospital in the country. On average, Pumwani admits 400 critically ill newborns each month from Nairobi and the surrounding areas. The hospital also provides a well-organized kangaroo mother care (KMC) service, which is an essential part of lactational support needed to save the lives of gravely ill newborns, along with donor human milk. The hospital primarily serves a low-income population, especially those living in Nairobi’s informal settlements, which have the highest rates of neonatal morbidity and mortality in the country, as well as very low rates of exclusive breastfeeding.
The study involved a combination of two major interventions: Establishing a human milk bank and improving lactation support for mothers of small and/or sick newborns. The human milk bank was set up in accordance with the Kenya National HMB guidelines developed in a previous phase of this project drawing from various reference materials that meet international standards. The process was led by the Nairobi County Ministry of Health and Pumwani Maternity Hospital, with technical and financial support from the global health organization PATH.
A total of 239 neonates were included in the study. Data for the pre-intervention group of 123 were collected six months before the establishment of the new HMB facility, while post-intervention data were collected from a new group of 116 five months after the HMB began operating. Participants were followed up to document neonatal feeding practices, length of hospital stay, and neonatal health outcomes during their hospitalization. The same tools and methods were used to collect post-intervention data as in the pre-intervention phase.
Promising results: The power of human milk banking and lactation support
Thousands of donated human milk units were voluntarily collected from healthy lactating mothers. These mothers had excess milk and expressed it for donation without receiving any compensation. In some cases, even mothers with a smaller excess of breast milk would also donate when their babies were admitted to the neonatal intensive care unit and couldn’t be fed orally due to illness.
An analysis of data before and after the intervention showed a significant increase of 54% in the proportion of newborns who were exclusively fed human milk during their hospital stay, from 41.3% before the intervention to 63.8% after. Additionally, the use of human milk for initial feeding (rather than formula or other types of feeding) increased by 52%, from 55.0% before the intervention to 83.3% after.
Encouragingly, the average length of stay in the neonatal unit also decreased significantly, dropping from an average of 1.8 days before to 1.6 days after the intervention. Although there were changes in some outcome indicators before and after the intervention, these changes were not statistically significant. These indicators include feeding intolerance, low birth weight babies, babies with respiratory distress leading to unconsciousness and potentially fatal asphyxia, severe bacterial infection (neonatal sepsis), and yellow discoloration (jaundice) among newborns in the hospital.
Stakeholder perspectives
It is not surprising to find that providing additional support to sick and vulnerable newborns, who have limited or no access to human milk during a critical stage of life, would lead to a higher rate of exclusive use of human milk. This finding was consistent with the observations made at the facility during the study and the feedback received from various key stakeholders, including women and healthcare workers. These stakeholders consistently expressed strong support for the idea of human milk banking and the provision of lactational support. The concept behind human milk banking involves promoting breastfeeding, encouraging the donation of breast milk, and utilizing donated human milk. As a result, the use of donor human milk as the initial feeding option was widely accepted to ensure an exclusive human milk diet.
Implications for Kenya and other sub-Saharan African countries
Sub-Saharan Africa’s very high neonatal mortality rate has led several governments in the region to invest heavily in preventing maternal and neonatal deaths, with a particular emphasis on expanding facility-based services. Kenya has launched initiatives to promote contraceptive use (aiming to decrease unintended pregnancies), enhance access to antenatal care, and increase the number of skilled deliveries. Ethiopia and other SSA countries have implemented comparable strategies.
In addition to its high burden of neonatal mortality, the SSA region is currently off-track to achieve the Sustainable Development Goals. SDG Target 3.2 aims to reduce the neonatal mortality rate to at least 12 deaths per 1,000 live births and eliminate all preventable child deaths by 2030. By introducing new and innovative interventions like HMB services, the region has a game-changing opportunity to address this pressing issue and decrease the high rate of neonatal mortality.
Taddese Zerfu is a Research Fellow with IFPRI’s Development Strategies and Governance (DSG) Unit based in Addis Ababa, Ethiopia. Opinions are the author’s.
This project was funded by the UK government under the County Innovation Challenge Fund (CICF) funded by the Foreign, Commonwealth & Development Office.
Referenced paper:
Wilunda, C., Israel-Ballard, K., Wanjohi, M., Lang’at, N., Mansen, K., Waiyego, M., Kibore, M., Kamande, E., Zerfu, T., Kithua, A., Muganda, R., Muiruri, J., Maina, B., Njuguna, E., Njeru, F., Kiige, L. W., Codjia, P., Samburu, B., Mogusu, E., Ngwiri, T., Mirie, W., Kimani-Murage, E. W. (2024). Potential effectiveness of integrating human milk banking and lactation support on neonatal outcomes at Pumwani Maternity Hospital, Kenya. Maternal & child nutrition, 20(1), e13594. https://doi.org/10.1111/mcn.13594
